Management of Modifiable Risk Factors Prior to Primary Hip and Knee Arthroplasty

Boraiah, Sreevathsa; Joo, LiJin; Inneh, Ifeoma A.; Rathod, Parthiv; Meftah, Morteza; Band, Philip A.; Bosco, Joseph; Iorio, Richard

doi:10.2106/jbjs.n.01196

Cited by 106 publications

(53 citation statements)

References 31 publications

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“…In the current orthopaedic literature, only 2 signifi cant studies have been published analyzing patients in a PSH model. Boraiah et al [14] recently published a study examining the utility of a scoring system, the Readmission Risk Assessment Tool, for TJA patients in their PSH model and noted that preoperative patient stratification could predict readmission rates. However, the benefits of PSH on patient outcomes were not directly examined.…”

Section: Discussionmentioning

confidence: 99%

Joint arthroplasty Perioperative Surgical Home: Impact of patient characteristics on postoperative outcomes

Phan

Ahn

Rinehart

et al. 2016

WJO

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AIM:To determine the impact of different characteristics on postoperative outcomes for patients in a joint arthroplasty Perioperative Surgical Home (PSH) program. METHODS:A retrospective review was performed for patients enrolled in a joint arthroplasty PSH program who had undergone primary total hip arthroplasty (THA) and total knee arthroplasty (TKA). Patients were preoperatively stratified based on specific procedure performed, age, gender, body mass index (BMI), American Society of Anesthesiologists Physical Classification System (ASA) score, and Charleston Comorbidity Index (CCI) score. The primary outcome criterion was hospital length of stay (LOS). Secondary criteria including operative room (OR) duration, trans- RESULTS:A total of 337 patients, 200 in the TKA cohort and 137 in the THA cohort, were eligible for the study. Nearly two-third of patients were female. Patient age averaged 64 years and preoperative BMI averaged 29 kg/m 2 . The majority of patients were ASA score Ⅲ and CCI score 0. After analysis, ASA score was the only variable predictive for LOS (P = 0.0011) and each increase in ASA score above 2 increased LOS by approximately 0.5 d. ASA score was also the only variable predictive for readmission rate (P = 0.0332). BMI was the only variable predictive for PACU duration (P = 0.0136). Specific procedure performed, age, gender, and CCI score were not predictive for any of the outcome criteria. OR duration, transfusion rate, postoperative complications or discharge disposition were not significantly associated with any of the predictor variables. CONCLUSION:The joint arthroplasty PSH model reduces postoperative outcome variability for patients with different preoperative characteristics and medical comorbidities.

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Section: Discussionmentioning

confidence: 99%

Joint arthroplasty Perioperative Surgical Home: Impact of patient characteristics on postoperative outcomes

Phan

Ahn

Rinehart

et al. 2016

WJO

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“…Boraiah et al and Iorio have discussed risk stratification and stressed optimization prior to joint replacement surgery, with special attention placed on modifiable risk factors. The opinion is that mitigating as much risk as possible preoperatively will decrease the risk of a complication or readmission [19,20]. Expectations regarding LOS and discharge location are set during this pre-operative process and are upheld with every service (orthopedics, anesthesia, physical therapy, nursing, etc.)…”

Section: Pre-operative Phasementioning

confidence: 99%

“…This necessitates orthopedic surgeons and anesthesiologists be willing to work closely together in their perioperative roles [11•]. There is much room for improvement in the pre-operative optimization process [19,20]. Furthermore, the PSH model can be expanded to include a greater control of the entire episode of care.…”

Section: Future Statementioning

confidence: 99%

The Perioperative Surgical Home: Improving the Value and Quality of Care in Total Joint Replacement

Chimento

Thomas

2017

Curr Rev Musculoskelet Med

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Purpose of Review The perioperative surgical home (PSH) is a patient-centered, physician-led, multidisciplinary care pathway developed to deliver value-based care based on shared decision-making. Physician and hospital reimbursement will be tied to providing quality care at lower cost, and the PSH model has been used in providing care to patients undergoing lower extremity arthroplasty. The purpose of this review is to discuss the rationale, definition, development, current state, and future direction of the PSH. Recent Findings The PSH model guides the patient throughout the pre and perioperative process and into the postoperative phase. It has been shown in multiple studies to decrease length of stay, improve functional outcomes, allow more home discharges, and lower costs. There is no increase in complications or readmission rates. Summary The PSH pathway is a safe and effective method of providing value-based care to patients undergoing hip and knee arthroplasty.

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“…2 Because of the association between comorbidities and poorer outcomes, [3][4][5] interest in identifying risk factors associated with adverse events [6][7][8][9] and strategies for preoperative medical optimization has largely increased. 10 Moreover, the identification of modifiable risk factors may allow for preoperative intervention, potentially improving outcomes and decreasing cost.…”

mentioning

confidence: 99%

Total Knee Arthroplasty among Medicare Beneficiaries with Hemophilia A and B Is Associated with Increased Complications and Higher Costs

et al. 2019

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Operations on patients with hemophilia A and B are complex. Studies evaluating postoperative outcomes and costs following total knee arthroplasty (TKA) in patients with hemophilia are limited. A retrospective review of the entire Medicare dataset from 2005 to 2014 was performed. International Classification of Disease 9th revision codes were used to identify patients with hemophilia A and B and they were matched to controls using a 1:1 random matching process based on age, gender, Charlson Comorbidity Index (CCI), and select comorbidity burden. The 90-day preoperative period was evaluated for comorbidities and the 90-day postoperative period was analyzed for outcomes and reimbursements. Logistic regression models were generated to compare outcomes between cases and controls. A total of 4,034 patients with hemophilia were identified as having undergone TKA. About 44.8% were between the ages of 65 and 74 and 62.4% were female. Although the CCI was identical in both cohorts, individual comorbidities not controlled for varied significantly. Medical complications were more frequent among the patients with hemophilia: postoperative bleeding (odds ratio [OR]: 1.7; 95% confidence interval [CI]: 1.2–2.3), deep venous thrombosis (OR: 2.3; 95% CI: 1.8–2.8), pulmonary embolism (OR: 2.9; 95% CI: 2.1–3.9), and blood transfusions (OR: 1.8; 95% CI: 1.6–1.9). Hemophilia was associated with higher odds of periprosthetic infection (1.78 vs. 0.98%, OR: 1.8 95% CI: 1.2–2.7). The 90-day reimbursements were higher for patients with hemophilia (mean: $22,249 vs. $13,017, p < 0.001). Medicare beneficiaries with a diagnosis of hemophilia experience more frequent postoperative complications and incur greater 90-day costs than matched controls following TKA. Surgeons should consider this when optimizing patients for TKA and payors should consider this for risk-adjusting payment models.

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Management of Modifiable Risk Factors Prior to Primary Hip and Knee Arthroplasty

Cited by 106 publications

References 31 publications

Joint arthroplasty Perioperative Surgical Home: Impact of patient characteristics on postoperative outcomes

Joint arthroplasty Perioperative Surgical Home: Impact of patient characteristics on postoperative outcomes

The Perioperative Surgical Home: Improving the Value and Quality of Care in Total Joint Replacement

Total Knee Arthroplasty among Medicare Beneficiaries with Hemophilia A and B Is Associated with Increased Complications and Higher Costs

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